CHAPTER 1
Why Should We Reduce Medical Overuse?

Karen Born1 and Wendy Levinson2

1 Institute of Health Policy, Management & Evaluation, University of Toronto, Toronto, Ontario, Canada

2 Department of Medicine, University of Toronto, Toronto, Ontario, Canada

IT STARTED WITH QUALITY IMPROVEMENT

The idea that poor quality and patient safety harms are unacceptable and can be measured and improved was introduced into mainstream medical and public culture in the United States nearly 25 years ago and subsequently spread around the globe. This can be traced to the release of a ground-breaking report, To Err is Human, published by the Institute of Medicine (Donaldson et al. 2000). This report was part of a multi-year effort led by the Institute of Medicine to change the discourse around patient safety and quality in the United States. To Err is Human focused on the issue of medical errors and safety issues. It highlighted systemic drivers that lead to errors and established a patient safety agenda with a focus on enhancing leadership, measurement, and systems to identify and decrease medical errors. It also highlighted that harm to patients from healthcare is a chronic threat to public health and is pervasive and preventable. This publication was followed shortly thereafter by the report, Crossing the Quality Chasm, which laid out an ambitious agenda for improving healthcare quality in the United States (Institute of Medicine 2002). This included establishing a six-dimensional framework to measure health system performance: safety, effectiveness, patient-centredness, timeliness, efficiency, and equity. In addition, Crossing the Quality Chasm offered three major categories for healthcare quality problems: overuse, underuse, and misuse. Overuse relates to healthcare services that have no benefits or for which harms outweigh benefits, underuse to healthcare services that offer benefits to patients but are not provided to relevant patients, and misuse to healthcare services that offer benefits in certain contexts but not others.

Subsequently, quality improvement collaboratives, campaigns, and efforts swept across the United States and other countries with wide variations in results and outcomes. About 14 years after the publication of To Err is Human, experts in quality and patient safety expressed frustration at the slow pace of change. In particular, decreasing overuse was rarely addressed by quality improvement efforts. The Institute of Medicine's report, The Healthcare Imperative, highlighted the shocking figure that nearly 30% of all healthcare costs in the United States were wasted or unnecessary (Yong et al. 2010). The report estimated that this unnecessary care, or overuse, costed upwards of $750 billion in 2009. The problem of overuse began to achieve more prominence as a quality problem, which necessitated further efforts to change. This figure of 30% of all healthcare being low-value has been reported in other high-income countries, including Canada (Canadian Institute for Health Information 2017). One commentary bemoaning the lack of change since the publication of the landmark reports over a decade earlier stated, in 2013, that, 'alongside important efforts to eliminate preventable complications of care, there must also be an effort to seriously address the widespread overuse of health services. That overuse, which places patients at risk of harm and wastes resources at the same time, has been almost entirely left out of recent quality improvement endeavours' (Chassin 2013).

This sentiment was supported by evidence that overuse is difficult to change. A United States study compared the quality indicators of overuse, misuse, and underuse in outpatient visits in 1999 and 2009 (Kale et al. 2013). The study found that during this period, 6 of the 9 underuse indicators improved, 1 of the 2 misuse indicators improved but only 2 of the 11 overuse indicators improved, with one getting significantly worse.

Chapters 2 and 3 will delve into why overuse is such a stubborn and challenging problem. And why strategies to reduce overuse need to be multi-pronged to be effective and supported by efforts to change the culture driving overuse, as well as systems that can drive overuse.

THEN CAME A FOCUS ON OVERUSE

Overuse was originally defined in the Institute of Medicine reports, and since that time, there has been a proliferation of terminology to define and describe waste and overuse in healthcare. Common terminology includes low-value care, unnecessary care, appropriateness, overdiagnosis, de-adoption, and de-implementation. Table 1.1 offers four categories to classify key descriptions for overuse. Note that positive language, such as appropriate care, high-value care or right care, has been used to contrast with overuse and to emphasis quality problems associated with underuse and misuse, as well as overuse, and as such are not included in the table.

This book will use the terms overuse and low-value care as they are consistent with the broader language used in the quality and patient safety literature. However, clarity regarding terminology can help to communicate the complex topic of overuse to various audiences.

TABLE 1.1 Overuse language and meanings.

OVERUSE AS A GLOBAL HEALTHCARE QUALITY CONCERN

In the chapter thus far, we have covered key American reports and data associated with the quality and patient safety movement. This movement spread globally, and with increased awareness of overuse came several key publications, which sought to describe and measure overuse in a global context. In 2017, The Lancet published a landmark special series of the journal with a focus on Right Care (Berwick 2017). The series emphasised the importance of the coexistence of overuse and underuse globally, offering evidence for overuse not just from high-income countries such as the United States, but also evidence of overuse in low- and middle-income countries. Also, the Organisation for Economic Cooperation and Development (OECD) released a report on overuse Tackling Wasteful Spending on Health in 2017. It began with a powerful statement contrasting spending pressures on healthcare systems globally with evidence that one-fifth of healthcare expenditures have no or minimal contribution to good health outcomes (OECD 2017). The OECD report linked the imperative to reduce overuse with the interconnected goals of spending less on healthcare while improving health. The OECD now includes overuse indicators, for example, antibiotic volumes, benzodiazepine prescriptions in older adults, and imaging tests in their annual Health at a Glance report (OECD 2021). The accumulation of evidence of overuse and presence of measures at the system level helped to articulate a case globally for the harms of overuse as a quality problem moving beyond costs. Importantly, these measures helped to emphasise a broad range of the harms of overuse to individuals to health systems.

It is important to frame and shape a narrative about overuse as going beyond wasteful healthcare spending to engage and motivate various stakeholders to take action. These include patients, clinicians, and the general public who may not be motivated to change due to government or payor concerns, but instead are concerned with individual safety and quality care (Born et al. 2017; Levinson et al. 2018).

Harms to individual patients from overuse include side effects from and medication interactions with unnecessary treatments, and incidental findings and testing cascades from unnecessary tests that can expose patients to risk. Overuse can also harm patients by wasting time or financial resources through delays in access to care, needless stress or worry, and wasted time and money pursuing follow-up appointments.

Harms to providers and organisations can be associated with wasted time, resources, and broader inefficiencies driving up wait times for patients and increasing inefficiencies for...